sb/sb/rg.
Date : 00.00.00

Name of the Patient : Abc Xyza Plmn / F / 70 yrs.
Referred by : Dr. Abc Xyz. Desai.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias since 3 years.

EXAMINATION :

M.R.I of the lumbo-sacral spine was performed using the following parameters :

5 mm thick T1 Weighted and T2 Weighted sagittal images.

5 mm thick T1 Weighted and T2 Weighted axial images.

OBSERVATION :

The L5 vertebral body is marked on the film.

There is loss of water content of the lumbar intervertebral discs. The L4-L5 and L5-S1 intervertebral discs show evidence of calcium/vacuum phenomena.

There is minimal forward translation of the L4 over the L5 and L5 over the S1 vertebrae, without obvious spondylolysis.

A small posterior and bilateral far lateral disc bulges are noted at the L5-S1 level.

A small pseudoposterior disc herniation is noted at the L4-L5 level with bilateral neural foraminal narrowing and impingement of the right L4 nerve root.

Left and right postero-lateral disc bulges are noted at the L3-L4 level with bilateral neural foraminal narrowing.

A small, postero-central protruded disc is noted at the L2-L3 level.
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Hypertrophic facetal arthropathy is noted at the L3-L4, L4-L5 and L5-S1 levels and facetal hypertrophy is noted at the L2-L3 level. Facet joint effusion is noted at the L4-L5 level.

The lumbar vertebral bodies show spotty fatty marrow changes suggesting osteoporosis. The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1 level and the thecal sac terminates at the S1 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

16.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
11.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

1. Minimal forward translation of the L4 over the L5 and L5 over the S1 vertebrae, without obvious spondylolysis.

2. A small posterior and bilateral far lateral disc bulges at the L5-S1 level.

3. A small pseudoposterior disc herniation at the L4-L5 level with bilateral neural foraminal narrowing and impingement of the right L4 nerve root.

4. Left and right postero-lateral disc bulges at the L3-L4 level with bilateral neural foraminal narrowing.

5. A small, postero-central protruded disc at the L2-L3 level.
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6. Hypertrophic facetal arthropathy at the L3-L4, L4-L5 and L5-S1 levels and facetal hypertrophy at the L2-L3 level. Facet joint effusion is noted at the L4-L5 level.

7. Tight lumbar canal at L4-L5 level.